=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063823870
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUZANNE R. MERICLE, DMD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2014
-----------------------------------------------------
Last Update Date | 03/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 MAIN ST
-----------------------------------------------------
City | ST SIMONS ISLAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31522-1680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-638-3559
-----------------------------------------------------
Fax | 912-638-0360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 MAIN ST
-----------------------------------------------------
City | ST SIMONS ISLAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31522-1680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-638-3559
-----------------------------------------------------
Fax | 912-638-0360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | SUZANNE R. MERICLE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 912-638-3559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 011052
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------